Chapters Transcript Video Aerobic Exercise at the Core of Rehabilitation Medicine…The Path to Follow… Jonathan H. Whiteson, M.D. presents at the Johns Hopkins Department of PM&R’s Grand Rounds on April 16, 2019. Share Fast Facts Watch Dr. Whiteson's grand rounds presentation on aerobic exercise at the core of rehabilitation medicine. Click to Tweet Thank you for inviting me. I really appreciate being here. It was a wonderful trip down from New York City this morning. Uh And um I'm gonna be talking to you about aerobic exercise at the core of rehabilitation medicine. The path to follow you may have seen this path. You know this path, the yellow brick road. I don't know how I got on to the Wizard of Oz, but it plays a theme in this talk. So I have one disclosure as a consultant to Nestle. Absolutely no relevance to this talk whatsoever. These are my objectives to understand the connection between physical inactivity, disease and disability, appreciate physical activity guidelines and the reason we don't achieve them. Understand the model of fatigue in disability, discuss the evolution of aerobic exercise as medicine has an impact on disease, disability, health, and longevity. Understand and apply the cardiac rehab model of aerobic exercise as medicine and cancer, brain injury and stroke rehabilitation and discuss a future state of rehabilitation medicine based on aerobic exercise. The bottom line is I think what I want to do want to do is implant a new a seed of thought about aerobic exercise and perhaps we can completely restructure this whole field of PM R all around aerobic exercise. Wow, that's very lofty. And I'm not saying that that's what you're gonna do. But I just want you to think about it for the next hour. I will apologize. I'm gonna have to speak fast at times and jump through slides quickly because I think I have 100 and 44 slides. Forgive me. I thought I was given 2.5 hours. That's a joke. Ok. Uh So this is not rocket science. We're not going to put a person on the moon or on Mars and the path may be a little convoluted just like this space rocket here. Uh Maybe it's a little bit like ducks to water because the first thing that we do when we start to become mobile is get up and walk as you know, 89, 10, 11, 12, 13, 14 month old kids, we know how to walk and get around. So really we're going back to the duck to water phase. And um this is Mr Magoo, I'm sure you all know Mr Magoo, but if he can see the benefit of exercise, then we should be able to as well. Uh Houston, we have a problem. I grew up saying this phase. I was always interested in space and whatever, but actually it was OK. Houston, we've had a problem here. It was Apollo 13 astronaut John Jack Swigart did you know that phrase? Did you say Houston? We have a problem. I, I grew up saying it anyway. Baltimore, maybe we have a problem. This is our problem is that too many people are dying from these diseases. These top diseases make up about 60 to 70% of the reasons why we die heart disease, cancer, chronic lung disease, unintentional injuries from behaviors and things that lead to those poor behaviors and stroke. So we need to do something about this. We need to understand what we can do to make a difference there to all those ailments that kill us. It's not just that they kill us, but we live with these diseases and disorders as well. 50 per cent of our adult population is living with at least one chronic disease and a significant number are living with at least two chronic diseases and it ain't cheap. Uh you know, uh who is it then? Um Doctor Evil, you know, when he says $1 million with two, nearly $3 trillion in annual health care expenditures in this country, it's, it's, I mean, you can make the world spend faster with that amount of money, but it's all related to the amount of chronic disease that uh you know, we develop. Uh and you can see, uh I think that's about a third of our population uh or the third of the expense it comes from people who have five or more chronic diseases and as I say, it's not just that we have these diseases or we live with these diseases or we die from these diseases, but we are disabled from these diseases as well. These are some statistics that, that show, you know, close to 13% of people living in the community with chronic disability. Uh Probably it's do we? No, we didn't lose it. Probably it's more than that, but certainly you can see that it's a more aging population, uh, that have the highest rates of living in the community with disability. If any of you know the movie, well enough, you'll know what is just about to happen at this stage of The Wizard of Oz. Yes. The scarecrow points, Dorothy in the wrong direction. This still the scene is called the wrong path. Uh So why do we go down the wrong path? And what relevance does it have for cardiac disease, stroke, brain injury and cancer? Because we choose to, uh because everything that we do is a choice, we choose whether to go left or right. We choose whether to, um, eat a burger or, you know, eat a salad, etcetera. And a lot of our choices influence the path that we're going to take in terms of our health. And certainly in terms of our likelihood of developing cardiac disease, stroke, brain injury, and cancer. Uh And, uh I don't know whether you have this impression, but I certainly do when I talk to my patients and they seem to be pointing at me as having the responsibility for their health. Uh, and I say, well, actually it's multi factorial and we all have a role and responsibility here. So the individual, the patient has a responsibility to take care of themselves. The physician, us, we health care providers have a responsibility. Uh, our families play a role too. Uh, you know, that, uh, complex social situations are going to limit the discharges and et cetera. So family community and the local state and federal government uh have something to do with it too. So when we look at the list, this list and say, well, if it's all these other factors, then really, is there anything that I can do about it? So this was an interesting article. Oh, there's lots of references here and I think they're all interesting and I would say read them all. So if you're bored on a Sunday afternoon, um then you should take these uh references and, and, and read them all. Uh but this was about self care prevention and management of cardiovascular disease and stroke. This came from the American Heart Association and they sort of broke down self care into the various different elements of, of, of what it looks like. So, self care maintenance is, you know, what can I do about myself to, to, to maintain good health and to avoid some of those risk factors for disease. But if I get those disease, then I need to do some self care monitoring. How can I keep an eye on be proactively involved with the observation of monitoring of those risk factors? And then if I have them and they're not well controlled or they're not going away, then how do I manage them? So these are sort of, this is part of a sort of a self care model. Uh That really helps us understand what we can do for ourselves. Based on this article, the American Heart Association came out with a life's simple seven. And I think it really is very simple. And again, I tell my patients this every single day when I see them, these are the simple dos. And don't that really make a difference to our life. So obviously, we shouldn't be smoking and I won't ask you to raise your hands, but I'm sure none of you smoke. We should all be trying to maintain the best possible body mass index. Normal is between 18 and 25 anything above 25. And we know we're heading in the wrong direction. Physical activity, I put it in red because that's what we're going to talk about a healthy diet, maintaining low cholesterol, normal blood pressure and plasma glucose. Uh So these are the simple things which if we take care of, then we're gonna have uh a healthier life and hopefully avoid some of these diseases. A healthy diet also includes from my perspective. No alcohol. How many people don't put your hands up, how many people can say they don't drink any alcohol? Well, I said, don't put your hands up because this is I, I'm not allowed to ask you to disclose about your personal lives. Uh But uh but the truth is, and there's a study that came out on Lance, I think it was like nine months ago now, maybe a little longer in the last year that looked, it was a global study and the safest amount of alcohol was zero. Uh So, so this is very interesting. I talk about this with my patients as well. Uh because uh you know, this is sort of the, the conclusion of uh of this uh uh the, the study that I talked about that was published by the American Heart Association. Because what they're saying is that really our behavior contributes to about 40 per cent of our overall health. And I think that's an underestimation. I think it's much more than that. And the reason is is that genetics, we're going to be discovering we are discovering that genes are influenced by our environment and by our behaviors and our internal environment as well. I what we put into our body. So if you smoke, your genes get altered by the tobacco smoke and toxins. If you eat poorly, then our cells and genetic material get influenced by, by that poor diet. If we don't exercise correctly, then our genetic material ages quickly. We see that people who exercise more have healthier telomeres on their chromosomes. So, genetics, I think we can positively influence this is not something I can do nothing about. So I think we'll see that our behavior actually probably governs much of the genetic influence as well. So there's always something that you can do. So let's look around the country and I'm gonna show you four slides and at the end of these four slides, I want you to tell me this is, you can tell me which are the two healthiest states to live in. So this is, this is the um this is physical activity. OK. This is our rates of excuse me, physical inactivity around the country. You start to get a pattern of where people are less active, the darker colors of those people who are less active. Uh What about obesity rates? So similar kind of pattern and diabetes rates? Oh, how about that? A similar kind of pattern? And what about hypertension rates? Well, you can see that in a certain region of this country, there's a lifestyle that does not lead to good health. But where were the two best states to live? Yes. Who comes from Colorado, Utah? Who's going? All right. So the World Health Organization also feel that this is worth looking at as well and they came out with a, an action plan. It's called the Global Action Plan for the Prevention and control of noncommunicable as in non infectious diseases. 2013 to 2020 they're sort of coming into the end of their action plan. But by 2025 they wanted to significantly reduce noncommunicable diseases. What were those diseases and the things that we're talking about? Cardiovascular disease, cancer, chronic respiratory disease and diabetes. And what were the four things that they said that we can do? Don't smoke, don't eat poorly, don't use alcohol, like I said, and be physically active. Well, now we have to understand what do we mean when we say physically active versus exercise. So when you wake up in the morning and you open your eyes, you have started to be physically active, but that is not exercise. That is not exercise as medicine, which is a nice phrase. I like to throw around. So that's just activity when you go to the gym and you look around you and you see people on the treadmill or the elliptical or whatever and they're texting or they're reading the newspaper or they're having a wonderful long flowing conversation with the person next to them. Trust me. I don't think they're exercising. They're being physically active. Exercise is something that is much more prescriptive and much more accurate and has a precise prescription which I'm going to get on to in a little while. But there's a difference between physical activity and exercise. I think we haven't quite sorted that out. In the literature. Yet there's still a difference because the question is still asked, are you physically active? And I think the two get interchanged, but I don't think we should be doing that. Uh, but anyway, uh, physical activity and exercise, if you look around the world, about a quarter of all adults are not physically active enough. I'm not talking about exercise but just being physically active enough and look at that, 81% of adolescents around the world are not physically active. Well, I have a 13 year old and a 19 year old. I know why because they're all playing Fortnite or whatever it is. Yeah, you know those games. So um so we got to do something about that. This was another study. This came out before that previous one I was talking about published in the Lancet looking at relative risk for all cause mortality, but also also for risk of coronary heart disease, diabetes, breast cancer and colon cancer and related to activity or physical inactivity. And there's a very strong correlation between all of those diseases and all cause mortality with the more inactive people are. So we see it on very large scale population studies. So again, this is an extension of that study, nine per cent of premature mortality. So 5.3 million people worldwide due to physical inactivity and if we could reverse that physical inactivity, by 10 per cent would save half a million lives. And by 25 per cent, 1.3 million lives and also people would live longer. So, physical activity has a worldwide influence. Uh, so, so here's where we are right here in, in the United States. Uh, so overall it's a, it's, it's, uh, you know, 1% to 19% and of course, on here it's so very small. Can you see what the numbers are there? 10 to 15. Yeah, I have 54 year old eyes and I can't work out how to use my reading glasses very well. So, but so here 10 to 15% of uh of our deaths are related to physical inactivity. Oh, there's a little island over here. You see that one? That's where I'm from. And I think that's a higher rate. That's over 15%. But I've adopted a more American way of life and I'm thinking of moving to Canada where I can be even more active or Colorado and Utah, one of the two. Uh So, uh so, so the these are factors that, that influence our, our self care and, and are things that, that we need to focus on as well and things that we need to understand in a model, but just in a societal model as well that there are individual factors including our mood. Uh and uh and you know, the, the number of disease that we have that influence our to exercise self care if we don't have good social support those people who are isolated, those people who don't have a loved one saying, come on, let's do something healthy that will influence our self care. And then if the community is not set up as well, if we don't have parks and recreation, recreational activities, if we don't have walks for MS and breast cancer, et cetera, then we don't get out there and be a part of the community. So what are the strategies that we can use to enhance our self care, to improve our behaviors? Well, there's a number of strategies listed here, but I think technology really offers us a tremendous amount of help and certainly within the field of rehabilitation medicine where, you know, sometimes the resources aren't always there, but we can stay connected with our patients through mobile technology and treating people in their communities. Certainly in the field of cardiac rehabilitation, that's really a wonderful area of opportunity for growth. But technology can really help people stay invested and engaged in their care. Uh So when we come to individuals with disability, we have an even greater challenge. And this is, this is part of the problem. This was a study that came out in 2004. You can imagine the data was collected in the, in the, you know, 19 9, 19. Yeah, in the 19 nineties. Uh So, so, so I don't think that there's been tremendous change in what we've been providing to patients. So this, this was looking at a group of disabled individuals and looking at what some of the barriers or facilitators were to their ability to be physically active or to be physically fit. And they interviewed a bunch of different people. They interviewed obviously individuals with disabilities, they interviewed architects, they interviewed people who were in the sort of the fitness and health world and city planners and park and district managers. And they came up with 10 different factors that either facilitate or impede behavior, um or, or, or ability to be active, including the issues in the environment and economic issues and a whole host of them that you can see here but clearly for our disabled population. This is a very complex situation. This is not easy. This is not like they're duck on the water. Uh This is, you know, somewhat challenging, but we need to approach it. So back to that slide that tells us what ails us and what kills us and what are we going to do about it. So when we think of cardiovascular disease, heart disease, a brain disease per arterial disease and leading to amputation, then we got to think about our modifiable and not un modifiable diseases as well as cancer. The same kind of risk factors have been associated with cancer have been associated with cardiovascular disease and physical activity is right up there at the top of the list alongside hypertension smoking, dyslipidemia, diabetes, overweight and obesity but those are the major factors that we need to look at. There are mechanisms that show that physical activity can actually positively influence high blood pressure, dyslipidemia diabetes. These are cellular hormonal genetic expression that is influenced positively by exercise that affect all of these risk factors when it comes to weight and obesity. Yes, it's complex. But it can also be looked at again somewhat simply in terms of calories in and calories out. A more active lifestyle will burn more calories. A less active lifestyle will burn fewer calories. But we certainly have, I think the tool at our fingertips and it is physical activity that helps to positively influence all those risk factors which can then go on and cause if we don't take care of, it can then go on and cause cardiovascular disease. So what should we be doing? How much activity? So our intrepid explorers now. So, so in the Wizard of Oz and on the yellow brick path, you don't see a car, there's no bus. These guys are walking. Great example. Even Toto is walking. Uh but this is what we should be doing. These are the 2008 physical activity guidelines. They were updated in 2018 last year, but I don't think that adds anything more to what was said in 2008. But so here it says, you know what the minimal requirement is, understand that word minimal. That's the lower threshold 150 minutes. Lots of people quote that as being, oh, if I've got 150 minutes a week, that's great. But this is where you should be 300 minutes. Ok. You can, you don't have to, don't raise your hand. But who exercise 300 minutes a week? That's five hours a week. Who does five hours a week? Ok. I said, don't, so, I don't know how many of you really do or don't. But, you know, in your heart, whether you do or you don't. But I know many of my patients don't exercise five hours a week and when I tell them, oh, you should be exercising five hours a week. You know what they do? They laugh at me. But I do, I get up at 10 to 5 every morning. So I'm in the gym, I'm actually in the gym from five till five till 6, 24 days a week. And then I play an hour and a half of soccer on a Sunday. So I get it in, I live it because I believe it. Uh, but this is what we should be doing. So how many of us are actually doing that? This is adults and how many adults are achieving the physical activity guidelines. That's the 150 minutes, not the 300 minutes. So, we're just about at 50%. We're doing better. The trend is up, we're doing better. But if you look at the age groups. It's actually the younger folks who are doing better and the older folks who are doing worse, this trend is in the wrong direction. What about when we combine aerobic exercise with resistance exercise? Because they're back on that slide, it did say 2 to 3 days a week of resistance exercise as well, were even worse. Only 20% are getting the combined amount of both and again, a similar trend, uh, from the younger ages down to the older ages. So, why aren't we more active? Why don't we exercise? Well, it's again, not straightforward. It's complex. And I know I have heard and you've probably heard all the excuses under the sun. Uh, but, uh, you know, fatigue is a big one and fatigue is an interesting one. So I'm picked out fatigue so that I could talk to you just a little bit about it. Uh, so we understand that there's general fatigue or fatigue just generally like, uh, you know, we can all experience it and there's fatigue in disease states as well. So let's talk about general fatigue and, and these next few slides come from this article. It's a very interesting article by Evans and Lambert again. Well, worth reading through if you're interested in, uh, fatigue, but they define fatigue as a physical or mental weariness. Yes, you've experienced that, you know what it is and your patients may also complain about it as well and it's an inability to continue the exercise that you're doing. In fact that you can actually, you actually probably have to stop or pull back from the exercise that you're doing. Uh, and this exertional fatigue is related to deconditioning. We're going to talk a little bit more about deconditioning in a little while. It's probably related to your muscle mass, not just your muscle mass but the functioning of your muscle as well. You've heard of the uh the term frailty. Yes. And frailty leads to sarcopenia and it tends to be this condition of loss of muscle mass, but it's not just the loss of the mass, but the muscle itself is not functioning well. There's a whole, there's a whole science of sarcopenia could be another lecture altogether, but it's very, very interesting and it's not something that's inevitable. It's not, but anemia as well. If you don't have uh blood cells to carry oxygen, poor oxygen extraction or poor Oxin delivery if you have lung disease and just in general, poor nutrition or malnutrition as well. Uh There's a patho physiologic classification, this physical fatigue, we were just talking about associated with muscular effort. You've been there, you've been in the gym, you're working out for an hour, you're starting to get tired in those muscles through the day. You're gonna feel it, that sense of fatigue in the muscles. It's actually a nice feeling, but still it's there. It's fatigue. Uh and uh then somatic which is considered perhaps more primary. It's uh a little more uh difficult to define, but it's a, it's, it's without physical fatigue without a physical exertion. But people just generally feel tired teasing out that mental or psychological classification as well. Mental, yes, you've been taking an exam, you're into the third day of the exam. You just can't focus any more. That's that mental fatigue and then a psychological fatigue, if you're anxious or depressed or blue mood, then you have this lack of interest and motivation. Uh So what about fatigue and sense of uh uh a physical fitness? Well, I deal a lot of this in the cardiac field in terms of our fitness level. If you remember from basic physiology days, the thick equation, the VO two is how much oxygen your body can use oxygen equals energy. OK? You've heard of Mets, not the New York Mets. Uh But uh that unit of energy, one med is your basal metabolic rate. Uh So the thick equation, how much oxygen you can utilize is related to how well your heart is pumping and how well your body is at extracting oxygen that's delivered around the body. So those are the central factors and the peripheral factors in terms of our determinant of VO two. And, and we know that when we perform regular exercise, we can increase our VO two because we can increase our cardiac output. Very importantly, that is significantly related to increasing our plasma volume expansion. So it's one of the earliest changes in our cardiac output. But it's also one of the things we lose quickest when we stop exercising is that your plasma volume shrinks back down again. Uh And in terms of our ability to extract oxygen, it's a whole host of different factors. These are some of the uh the, the, the bigger ones capillary density increases, mitochondrial density increases. And myoglobin which has a higher affinity for oxygen than hemoglobin does at attracting the oxygen from the red blood cell. So what about fatigue? You've been there? You've experienced it. You may have got a Charlie horse or a crab or overdone it and have hit that wall. That wall is when you are reaching what's called lactic lactic acidosis, lactate threshold, anaerobic threshold. That's where we are converting over from aero metabolism to anaerobic metabolism. And that lactic acid builds up whenever you've experienced that, then you are going to experience that mental fatigue, the drive to respiration because you are now in an acidotic environment. Tachycardia. These are the kinds of changes that we feel when we cross that threshold of fitness. Lactic acid is gonna come up again in a little while in relation to cancer. What are the other causes of fatigue? Well, if we haven't fed enough, we don't have enough glycogen. If we have not drunk enough and dehydrated temperature regulation issues. Vitamin D as well. Also related to fatigue and dopamine depletion as well. So, a number of different factors also contribute to fatigue. This is that was generalized fatigue. Well, what about fatigue in disease states? Well, if you have, if you take care of patients with traumatic brain injury, you'll understand and you know that many of these patients will complain of fatigue, ranging from the thirties to 70 per cent. Even in people with mild injuries, mild concussions can have fatigue but more prevalent in those with moderate to severe injuries. And it's related to neuronal injury. It's, it's and it's in those areas of the brain where you see the most impressive diffuse axonal injury. So, you know, this fatigue and traumatic brain injury it's associated or it's more prevalent in in those environments or times when there's increased effort, not just physical effort but mental effort. There could be neuro hormonal abnormalities including abnormalities of growth hormones. And then there are neurotransmitter issues as well. So there are some complexities to this. This is a model of of fatigue and traumatic brain injury. Obviously, it links the neuropsychological, the endocrine dysfunction, the exercise issues. But it all sort of relates to, you know how fatigue develops in an individual with traumatic brain injury. Again, it's not just an acute issue and it could be a very chronic issue issue as well. What about fatigue and stroke also very prevalent. Also multiple factors are related to fatigue and stroke. But I think one of the very interesting ones is this issue with sleep sleep disorder. It's very common in people with stroke. In fact, sleep disorder is very uncommon, very common in people with cardiovascular disease in general. I don't know how many of you actually ask your patients about sleep, difficulty getting to sleep, difficulty staying asleep, snoring, fatigue when they wake up and falling asleep during the day. These are some of the markers of sleep disorder and very much associated with uh with cardiovascular disease and stroke and fatigue and stroke. And this is a model of fatigue and stroke. Again, I'm not going to spend too much time on it, but it's a, it's a very interesting model of, of how fatigue is originates and then feeds back into itself. This was a study that was published back in 2012 and it was a study to look at um cognitive therapy versus cognitive therapy combined with, with a graded exercise therapy or graded activity in terms of combating fatigue. And what they found was after a 12 week intervention that both cognitive therapy and exercise therapy or activity improved fatigue. But there was no doubt that the combination of the two was better than the one alone. So again, you cannot hope to overcome fatigue and stroke by only giving cognitive therapy or perhaps only giving exercise. But you should be combining both modalities. What about fatigue and cancer also very common as well? 74% 3 quarters of patients who have cancer will say that at some point in their course, they have fatigue and on a daily basis, one third of patients with a diagnosis of cancer will complain of fatigue. Many of them have had it for many, many years. And sadly, 50% it's never been discussed with their clinician and only in 25 per cent has any intervention ever been proposed? 25 per cent of those that it's been discussed. So we're not doing a very good job in cancer in general in terms of understanding or talking about fatigue. Again, it's multi factorial in its origins, probably a lot related to the tumor. A lot related to the the therapy, pain, anxiety, metabolic issues, other comorbidities that may be coexistent or may develop subsequent to the diagnosis of the of the of the cancer opioid analgesics may have something to do with it. So sleep disturbance as well. So again, this is multi factorial. Um this was another review article, by the way, again, well worth reading over, published in 2012. And it really talks about exercise recommendations. This is where I got a lot of the information about fatigue and cancer talks about a lot of the exercise recommendations to try to overcome fatigue and cancer. Uh And so again, well worth a read. And what about fatigue and cardiac disease in the area that I work in? Again, I see it across the board in heart failure. It's the most common, most commonly see fatigue out of all the diagnosis and heart failure. But you see 70 to 80 per cent of patients will have it, it gets worse with rest. It's very interesting. I think a lot of these fatigue states get worse with rest many times. It's our inclination. Oh, if I'm fatigued, I'm going to rest, I'll feel better once I've had a nap or a rest or sat down for an hour. But that's actually not the case because we worsen our deconditioning. It's associated with poor cardiac output, metabolic abnormalities, neuroendocrine and hormonal abnormalities, endothelial dysfunction and of course, mood and emotional disorders as well. So here we have a state of affairs where we're dying from preventable diseases. We understand we have something to do with it. Fatigue has a lot to do with it. And we understand that in brain injury and stroke and cancer and cardiac disease, it's multi factorial, it's complex. But what can we do about this? Well, we have to understand initially what the concept is of motor activity. And you'll see here the evolution of motor activity uh from a sedentary behavior all the way up to exercise as medicine and then exercise is rehabilitation. And when I use the word exercise, I mean aerobic exercise, although I am corrected, many people will say to me, yes. But what about the resistance exercise too? That's also very important. That's the topic of another talk, you'll have to invite me back. Uh, so we have a long history of understanding about, uh, about, uh heart disease, not back about, excuse me, about activity and the benefits of exercise right back to the 19 fifties that, that London bus, you'll recognize that was one of the earlier studies to look at about, at activity and exercise in London bus drivers and found that those who were more sedentary, had higher risks of cardiovascular disease and those who were more active and these people were driving around for 8, 10 hours a day sitting down. So, but we've had a long history of, of of, of articles being published about the benefits of exercise. So again, a little bit tongue in cheek, but exercise equals life, exercise equals immortality. I do say that to my patients again, they give me a chuckle and then I add that little term phrase nearly. But I do believe that while we cannot become immortal, we can approach immortality. And that's not from an ego perspective. So this is very interesting. This, this research looked at endurance trained individuals and these were endurance trained individuals who really endurance trained for most of their lives versus sedentary individuals who were sedentary for most of their lives. So look at the decline, this is the V two, this is the oxygen carrying capacity. Look at the decline in the sedentary individuals. So here they are at 50 years of age and physiologically they're equivalent to an 80 year old trained individual. So that's, that's, you know, very, very interesting, uh, alternatively, an 80 year old individual who's, who's trained all their life is physiologically like a 50 year old. Ok. So physiology has a lot to do with our life expectancy and it's borne out in this slide as well, which shows you that the relative risk for all cause mortality is absolutely directly related to the fitness level. You have the least fit to the most fit, the more fit you are, the longer you're gonna live. I like that idea. Uh, this is why I go to the gym. I tell my patients as well. They chuckle too. I'm gonna live to 100 at least 100 and I, and it is a little funny but it's not, you know, there's no reason we shouldn't expect to live well into our hundreds. If we follow life. Simple seven, this was a study looking at physical activity in an older individual group. And again, the benefits of excise is not just for youth or middle age or across the board. Uh, but this was a study that looked at, um, you know, walking physical activity in a, in a group who are older. I think the average was 73 yeah, 73 years of age. Uh, and they found that physical activity was inversely related to coronary heart disease and stroke and, uh, and, and death. So again, a direct correlation between activity, walking and survival at any age. Do we have examples of medicine uh of exercise as medicine and rehabilitation? Well, the answer to that is yes, we have in general. Uh and I have 20 of those, 30 years, but it's at least 30 years, probably much longer than that back to the 19 seventies uh where we started to understand about the cardiac and pul rehabilitation, about the benefits of aerobic exercise in that population. So we're getting close to the Emerald City. Our goal, they just had a nap. By the way, they're coming out of that, those flowers. That's where I think they were drugged, weren't they drugged? Then they all fall asleep, didn't toto fall asleep and Dorothy, I haven't seen it for a while. Ok. So, so, so what is the cardiac rehabilitation model? And then again, you know, I'm giving you this because I think this model should be extrapolated to, to, to what you're doing in stroke rehabilitation and cancer rehabilitation and brain rehabilitation. So, so think about out this, as I talk about it briefly, how you could perhaps incorporate this into your, into your other models of care. But it's a comprehensive approach. Yes, that's what we do in the rehabilitation world and we look at the patient from toes to nose. So, you know, it's not just about looking at a region or an organ system, but we look at absolutely everything in terms of our history and physical and our tests and our management plan and the management plan, we sort of have our feet in both spheres of primary care and specialist care. But primary care from my perspective, I'm always looking into and asking and I may not be ordering the test, but I'm pushing the primary care physician or the cardiologist, make sure that they have checked out the lifestyle risk factors as well and make sure they're on the right medications and make sure they're taking their medications. And then as a psychiatrist, because these patients come with all different levels of, of strength and mobility. So they may need a more sort of basic comprehensive plan of physical and occupational speech therapy. Many of them have cognitive or emotional issues that are clouding their path. So psychology, nutrition is very important and then the cardiac rehabilitation program. So the cardiac rehab program always starts other than that evaluation with a stress test because we have to understand what the body can do and how hard the heart has to work, to get the body to that level and to make sure there's no major disasters on the horizon. Like for cardiovascular disease patients, arrhythmia, heart failure or ongoing ischemia. These are the major issues that we check for in a stress test. We want to know what their functional capacity is. We want to make sure they're safe on equipment because you're going to put someone on a bike on an elliptical or a treadmill or a rower. We want to make sure that uh from all perspectives they're safe, we want to make sure that we understand their risk for a problem, a medical problem or any other kind of issue because that comes into our exercise prescription and the exercise prescription is the crux of the matter when it comes down to exercise as medicine. So, uh the excess prescription, uh we uh abbreviated into the little term there fit p frequency, intensity type and time and progression, which I'll come on to again in a little bit. But in brief, it's 2 to 3 times a week when somebody is on a sort of an insurance pay for outpatient program, 23 times a week, 36 sessions, typically aerobic exercise. But we also do incorporate some resistance exercise as well. And for some patients, high intensity interval training is also important and then flexibility, posture and balance as well. The idea that cardiac regulation is a lifelong program. So it's not just 36 sessions and I do dislike intensely the term maintenance therapy. I prefer the concept of lifelong exercise, lifelong training. So we transition our patients from outpatient cardia, we have into lifelong training and before we launch them onto their own, we get an exit stress test, we compare it to the first one to show the progress uh and confirm, you know, confirm the gains, make sure they're safe and we modified the exercise prescription. Uh, and then we try to ramp up the frequency. Like I say, I tell my patients 4 to 5 days a week, target 300 minutes of moderate, intense, hot, hot sweaty work. That's what I tell them. They got to leave that gym, you know, puffing a bit, a little taco a lot and fatigued. There's the fit formula frequency, intensity time type and progression. Uh, typically the type is aerobic training. Although we do bring in aerobic training as well, the goal is up to 4 to 5 times a week. Anything is better than nothing. So, this was a study called the I think the Weekend Warrior study. And it looked at individuals who were inactive, got no activity whatsoever all the way through to those who were sufficiently active and they met their goals of the physical activity guidelines. And what they found was that the all cause mortality was significantly decreased with the greater frequency of exercise from those who are inactive to those who did it once a week to a couple of times a week to three or more times a week. And what about the intensity of exercise? So, uh here this is people who got no physical activity, they had a crude death rate of eight and change. Uh Who anyone who does a little bit more than no physical activity even below the 300 minutes has a reduced crew death rate. But once you start to introduce some more vigorous activity. So this was 00 to 30% of the time was vigorous activity here. Yes, sir. Yeah. So vigorous, I think was like over six Mets, which actually in my book is actually not that vigorous. It's actually somewhat mild, but that's how it was defined in these studies. Uh No, no, no, this is not, this is not walking. This is so what you're gonna feel is sort of a moderate intense uh experience when you are exercising at that level. OK. So you're, you're gonna feel um that your heart rate is getting up, you're gonna feel that sense of fatigue and gonna be getting hot, you're gonna be getting sweaty. Um Again, if you think of it in terms of conversation, you're gonna be able to speak in short sentences as opposed to long paragraphs. OK. So it's, it's a, it's a perception as well. The R pe scale correlates very well, the RP scale of 12 to 14 correlates very well with this kind of intensity of exercise that we're looking at. You're welcome. So when we start to bring in more vigorous activity in terms of the amount of time, then we start to see that our uh death rate decreases. So the lowest amount of death rate is 300 minutes with at least 30% of that time at a high intensity level. Uh These are a couple of references that if you're interested in high intensity training are very applicable to the cardio pulmonary field. But this is intense in terms of what the model looks like. So this is a steady state, the darker line and this is the interval training with three or four intervals for every piece of equipment. Uh This is uh in terms of the time, this is an interesting uh study as well in terms of the time. So if the, if if people are not exercising at all, they are at their baseline, they're sedentary, even those who have less than the physical activity guidelines, in terms of the amount of time they have a reduction compared to the sedentary lifestyle and those who reach the physical actually over the physical activity guidelines. This is about, I think 400 to 500 minutes of exercise a week, they have the greatest reduction. What's interesting here and this is I think 10 times the. So these are the ultra marathoners, the iron, the iron folks, men and women, you know, it's not always so good. There is probably increased stress through the cardiovascular system, increased inflammation, which actually increases their mortality risk. So, you know, the old adage, if something is good for me, more is better, that's not always the case. Uh So what about, you know, cardiac rehabilitation as, as, as medicine, cardia rehab, really having an influence on the outcome. So this was a study published back in 2010. The relationship between the number of sessions attended in terms of cardiac rehab and death and myocardial infarction at four years. So we're looking at exercise, not, you know, blood pressure control with this medication or stroke control with that medication, but exercise. And did it have an effect on your risk for death and heart attack? Well, the answer is yes. So, so these were the people up here in the, in the dotted line who got the fewest number of sessions. And you can see this is the cumulative incidence of death, a lower risk of death after four years for the more sessions, 36 sessions. So this was these were people who did 30 six sessions and then we didn't tell them whether they should carry on exercise or not. They just lived whatever lifestyle that they had incorporated or continued. But 36 sessions, three months of exercise produced a significant reduction in mortality four years later. And the same, for instance of myocardial infarction compared to those people who did fewer sessions. So there's clearly some hangover effect of the benefit of cardiac rehab. And this was looking at readmissions on mortality. I think this was over a period of 10 years after myocardial infarction and this is the the hospitalization or the readmission rates. But you see a 50% reduction in mortality rates for those people who participated in cardiac rehab versus those who didn't. So cardiac rehab, the model, the exercise is medicine. It does have significant positive outcomes for patients who have cardiovascular disease. Jumping over a few slides just to make sure we've got time. So what about excise is medicine in the field of cancer? So what, what does epidemiology, epidemiology? Tell us. Well, if you look in terms of populations, we understand that those people who are the least active have the highest risks of uh of these cancers, prostate breast colon, lung ovary and, and endometrium. This was a study, a global study, nearly 1.5 million patients. And they pulled the data and they looked at leisure time, physical activity and risk for cancer and found that those who had the highest levels of physical activity had the lowest risk of cancer in these, in these kinds of cancer. Ok. So compared from the highest amount of physical activity to the lowest amount of physical activity, you had a significantly lower risk of cancer in these 13 cancers. Another epidemiologic study, a meta analysis done in 2009, looked at risk for colon cancer and found that those people who were active had a 24 per cent lower risk of colon cancer compared to those who were the least physically active, similar study in breast cancer. Ok. Reduction of risk of breast cancer by 12 per cent, similar in endometrial cancer as well. Reduction in higher physical activity versus lower physical activity by 20 per cent. So, so this is that was the the the risk of cancer in terms of epidemiologic studies and these quotes are all about patients who have been diagnosed with cancer and the risk of cancer recurrence. 35% lower risk of breast cancer deaths in people who exercise 41 per cent of risk of all cause mortality. 24 per cent low risk of breast cancer recurrence. Similar statistics in terms of colorectal cancer, in terms of exercising physical activity that was started after the diagnosis of cancer. And it's complex, it's not straightforward. It's not the one reason why exercise improves, improves your outcomes. In terms of cancer, probably related to various different levels of hormones, obesity, insulin resistance, inflammation. I'm going to show you a slide in a few minutes about inflammation and a leading researcher is talking about inflammation and cancer, a function on the immune system as well. Um Lactate production, I told you we'll talk about lactate and cancer in a few moments as well. Uh transition time of bio acids in the gut. Uh and that and genetics gene gene expression epigenetics again, probably has a significant impact on your risk of cancer with exercise. Uh So this is just a, a model of, of, of what I said in terms of the benefits of exercise, having effects on sex hormones and in various different inflammatory markers and signaling molecules in terms of uh cancer development. So I don't know if any of you have heard of ingo San Milan, he's a researcher out in Colorado in the rehab department out there. Uh And uh he talks about um a physiologic mechanism called the Warburg effect. And it is all about the production of lactate and lactates influence on cancer. And again, I put this here not to go into this tremendous detail about it with you today. Uh But uh but lactate uh that byproduct of inefficient exercise, uh that byproduct of a sedentary lifestyle uh is uh associated with carcinogenesis. Uh And uh and so therefore, uh we need to recognize that lactate plays a role here and exercise plays a role in improving our metabolic pathways, uh reducing uh glycolysis and improving our um oxidative metabolism in the mitochondria. And that shift from dependence on glycolysis to aerobic metabolism through the creb cycle in the mitochondria, uh helps to spare the body of this lactate overload. And therefore, is probably one of the reasons why we see a reduction in cancer in those people who are aerobically fit because they have better abilities to shift away from lactate production. Again, read the reference. It's tremendously interesting. This is another researcher, his name is uh Lee Jones. He works now up at the Memorial Sloan Kettering. And again, he has a slightly different theory in terms of the uh the etiology of cancer. And it's based on in inflammation, chronic inflammation and inflammatory markers and the effect of inflammation on immune modulation and the role of immune modulation in uh tumo gene in cancer. And he's done most of his work in the mouse model and the urine model. But again, read his research, it is so compelling in terms of the reduction of inflammatory markers with aerobic exercise and the delayed growth of tumors. So, this was a study that looked at mice who were injected or transplanted with a human breast cancer model. And the top line is those individuals who were set into carry. And the bottom line is those individuals, the mice individuals who were active and this is the weight of the tumor. So you can see that these lines are diverging, that the tumor grows far quicker in sedentary individuals than it does in active individuals. And this graph here, this is looking at the the sedentary individual and then patient mice that were treated with chemotherapy and cologne and exercise alone. And then this dark line is the uh chemotherapy combined with aerobic exercise. Those mice that had chemo and exercise had the smallest volume tumors. We've got to show that that's the case in the human model. But this is a human breast cancer model in mice, again, very compelling data and again, very well worth a read. Uh So how are we doing in terms of uh activity, promoting activity and exercise? So those people who have cancer, uh very few of them are actually exercising and as they recover, still far fewer than we would like to exercise are being active. So we need to think about that. If you have a cancer rehab program here, if that's an area of interest of yours, you've got to think about how you're going to be able to get in there and motivate these patients to exercise and give them goals that they're able to achieve and get them on that path so that you can get your patients who have been diagnosed with cancer to exercise because it makes a difference to their outcome. This was a Cochrane review in terms of not just outcome in terms of survival, but in terms of quality of life and showing that in cancer survivors, physical activity was related to reduced fatigue and depression and improved quality of life. Here's some more reading for you as well. Uh The couple of articles are gonna be uh published uh The American College of Sports Medicine is gonna come out with some statements uh later on this year. And again, I really encourage you if you're interested in this field of aerobic exercise in cancer and cancer rehabilitation that you should be reading these things. So what about exercise as medicine for the brain? Uh This is uh Julie Basso and Wendy Suzuki. I think Wendy Suzuki is up at NYU. Uh But this is also interesting data. I made it a little bit larger. Of course, I cannot see this at all from the slide here. Uh But this looks at various different behavioral models and I think neuropsychological models and etcetera in terms of the influence of exercise on various different markers uh within, within the body. Uh This is um again done by Wendy Suzuki. This was a study of the neural effects of exercise. Uh And uh um you know, you got your little mouse on a, on a running wheel here and there is some data to show that there's a hippocampal neurogenesis and that therefore improves learning and memory and mood. And this is all related to this Myo cathepsin B that gets released by, you know, from the peripheral muscles, exercising that crosses the blood brain barrier gets into the brain and improves neurogenesis in the hippocampus. This was an extension of her study by another two other researchers and they looked also at the hippocampus and these brain biopsies of sacrificed mice. And these black dots represent neuronal activity in individual mice. These mice were sedentary, these mice walked around a maze and these mice ran on that running wheel. So the more activity you had, the more more neuronal activity you had. And this is essentially neurogenesis, this development of new neuron, new new neurons. So this was the uh the hypothetical model that they put down. Again. The study has been done in mice. It's a little harder to sacrifice human beings and test their hippocampi. Uh But, but I think this, you know, the models are, are close enough to understand that exercise improves our neurogenesis centrally. Um This was a study looking at dementia. It doesn't, didn't mention whether these patients had Alzheimer's disease or not. So I'm not going to claim exercise is a cure for dementia, although I'd like to. But again, this was a model that looked at brain derived neurotrophic factor and hypothesized that that exercise, you know, improved brain derived neurotrophic factor and therefore, would have a positive influence on the rate of progression or even the chances of developing dementia. What about uh what about concussion? So this is very interesting as well. Uh because you see a lot of exercise and intolerance after concussion and it's felt that that's related very much to abnormalities in the autonomic nervous system. Uh and the autonomic nervous system controls uh ventilation. Uh So you see an abnormal ventilator pattern in individuals who have had a concussion and it actually leads to an inappropriately low rate of respiration in individuals when they're exercising after a concussion. And therefore, they have elevated levels of carbon dioxide and those elevated levels of carbon dioxide uh cause vascular changes in the brain which lead to a headache, dizziness, and fatigue. So, so, so this is a sort of somewhat theoretical but also known to occur as well in terms of venture abnormalities and individuals who've had a brain injury. So, so this group, John Leddy is a leading researcher in this field of exercise in concussion and these symptoms, they developed this test, the Buffalo concussion treadmill test or bike test to really try to understand what the right dose of sub maximal exercise is for individuals who've had concussion, who need to exercise. But don't want to get to that point of hypercapnia that they're starting to have symptoms of headache and dizziness and fatigue. Because when you feel like that, when you're exercising, you're going to pull back from your exercise. So this was the model that, that, that they devised, that divided the patients into sort of four different groups. And depending on how they did with the, with the, uh with the, uh with the exercise training test, if they had no symptoms and they were free to get on and return to sport. And if they had some symptoms, depending on what they were, then it would dictate the different kinds of rehabilitation care that these individuals had. And one of the models that he looked at was a female college athletes who had a concussion and found that they had elevated levels of arterial carbon dioxide. And he trained these individuals and found that using his model of evaluation, the treadmill or the back test to find a sub threshold to a level of aerobic exercise that did not induce symptoms, he was able to help these college athletes overcome their concussion symptoms far quicker than those individuals who didn't exercise. Um This was a, another study also by lady. In fact, I think this one was just published in February of the, of this year. This was the first prospective randomized controlled trial of sub therapeutic aerobic exercise in individuals with concussion finding that, uh, you know, there was a significant significant improvement in time to recover. These were the sedentary folks, these were the ones who were exercising and on a randomized controlled prospective study found that aerobic exercise spent the time for recovery and, and reduce the severity of the symptoms of post concussion syndrome. This was a study that was done that I put in here to sort of indicate that this is not just necessarily an acute intervention. This was a group of individuals who were involved in a, in a walking versus a nutrition program on average eight years after they had a traumatic brain injury and the outcome showing that there was no benefit of, of a nutrition program, but absolute benefit in terms of reduction and fatigue and increase in step length through a walking program. So even eight years following a traumatic brain injury, the benefits to aerobic exercise for individuals with traumatic brain injury is noted this, this study was a systematic review of looking at aerobic exercise and quality of life in patients who had a stroke. Uh, and found that when you pulled all the data together of individuals who had had stroke and who got involved with aerobic exercise, uh, found what that, you know, the aerobic exercise improved aerobic fitness, improved their walking speed improved their endurance. Again, a very good article to, to read because at the end of it, it gives you this, uh, this, uh, this uh model of a, of a rehabilitation program that you can take right from these pages and put right into your system of, of care for individuals with who've had stroke. It's very prescriptive and it's very effective in terms of outcome. Um So this was, this was a study as well that was looking at neuroplasticity and the benefits of aerobic exercise. And the reason I put this one in here as well is because in the acute rehabilitation stage, the value of aerobic exercise is that it primes the body for neuroplasticity. So, when I was at medical school back in England in the 19 eighties, neuroplasticity was only something that we talked about in terms of Children. Once you reached a mature brain, uh then there was no, we did not think there was any neuroplasticity still uh to, to be, to be operated on. But now clearly we're understanding that neuroplasticity continues throughout the lifespan. But it is the timing of the aerobic exercise in the acute stage that really can enhance or prime the brain and prime those neurotransmitters to then enhance the uh the recovery uh of of a stroke directed rehabilitation program. So if you have a patient with a hemiplegia and and a weak hand, get them to do aerobic exercise that primes the brain with all these neurotransmitters and then they're gonna benefit more from doing their hand focused rehabilitation. So, do we have a magic pill? Um I happen to think yes, but I'm very biased. I believe all this data again, I may be very biased. But I think there's a growing amount of evidence that shows the value and the benefit of exercise and not just in cardiac rehab. But I think there's compelling evidence in cancer in terms of prevention and in recovery and prevention of recurrence in terms of prevention and recovery, in terms of stroke and in terms of management, in terms of brain injury. And I think there's probably much more to be learned in terms of rheumatologic disorders. Uh So we're just about knocking on the door of the Emerald City. Now, I think we're sort of reaching the end of our journey. Uh And, and hopefully you have some understanding of the value and benefit of where aerobic exercise can play a role. So, so that's the question really I have for you, how are you incorporating or going to incorporate aerobic exercise as medicine in your rehab program? You have examples of cardiac rehab and py rehab, cancer rehab is getting on the bandwagon as well. There are plans afoot to establish a prospective study based on a cardia rehab model of a aerobic exercise in cancer rehab population to look at outcomes. I think the same should be done in terms of brain and stroke rehab in other neurologic conditions as well in immunologic mediated disorders of rheumatologic conditions and a lot of the arthritic conditions as well. And then in any area where we feel that genetic health or expression is influenced as well, how do you incorporate this cardiac rehab model? Well, it needs to be a comprehensive program. It needs to be across the continuum of care. There's never, it's never too soon to start. So you can go into the IC U and you can go through a lifelong interaction. Again. We've got to change behaviors, our own, as well as those of our colleagues and our patients. We need to make sure that we have compliance because this is not 36 sessions and then you're cured, this is lifelong. So you've got to keep it up. We need to partner with our specialist teams, we can't do this alone and we need to build, we need to make it relevant to the health care environment. So building it into value based management showing that your intervention in the acute stage and the chronic stage can actually alter the course of disease and therefore be a cost savings to the system, but also be a value to the patients. So what's the next steps? We need to do research? There's no doubt about it, but you can start now, you can think about what you're doing now about incorporating aerobic exercise into your current programs. And then also when you prescribe physical therapy or occupational therapy for your patients, why not add on aerobic exercise? You can do just 10 minutes of aerobic exercise at the end of your physical therapy program. So what are my plans for the future when I take over the world? So I think this needs to be part of departmental strategic planning. I think it needs to be part of a health system, strategic plan. I think A A PM R all of our organizations, Associate Association of academic psychiatrists, a etcetera. They all need to be on board. And, and I think we need to affect and change residency training as well. And we think we need to add aerobic training into the focus there and, and think of this across the board. Um at 1 28 I think I made it with two minutes to spare, which saves me from many significant questions. But uh but thank you for listening. And I hope, as I said at the beginning that you will think about aerobic exercise as a way to treat your patients as you manage them in every stage of your care. Thank you. I'm happy to take questions. Great question. Um I know you were making a point about um being physically active versus exercise or exercise and I wanted to get a better, better peer view in terms of what we define as a dia exercise component. Are there specific parameters that we would like to have as a guideline for our patients, be able to kind of achieve the number of minutes required. Yeah. So that's another lecture as well. But in brief, in brief. So as I said, when you wake up and you open up your eyelids, that's activity and when you're walking around and going to work, that's activity. But the exercise needs to reach a certain threshold, the certain intensity and typically we do that through a heart rate and that heart rate intensity certainly in the cardiac rehab world. In terms of risk factor modification needs to come from that stress test that we do. Uh, a more complex stress test is called a CPA cardio pulmonary exercise test that helps us understand aerobic anaerobic threshold. And we tend to want to exercise patients below that anaerobic threshold. So we take that into account the metabolic, uh, fitness of somebody and their heart rate. And then we come up with a heart rate zone that allows people to exercise in a safe zone below that anaerobic threshold. And then, uh, is part of the prescription. If we're talking about prescription for exercise, it needs to be that intensity. It needs to be a certain frequency up to five days a week and needs to be of a certain duration, one hour each time or 300 minutes. So that's, that's how you're going to get your patients into, into an aerobic zone. It doesn't happen overnight. So I last weekend, I was out at the Shirley Ryan Ability Lab and they are incorporating aerobic exercise, higher intensity training in their stroke patients. They're acute stroke patients. They're putting them on a treadmill and harness supported walking and they are getting them to do higher level of exertion, higher level than what? Well, if they weren't supported and weren't on the treadmill and didn't have the therapist helping advance their legs. They could walk maybe, you know, 10 steps in five minutes. But here they're walking at, you know, two miles an hour, 2.5 miles an hour with harness and therapy assisted ambulation, their heart rates are increasing. So it's a scale, a graded scale. Hopefully that stroke patient that I saw walking is going to recover to the point where they can do their own bike and treadmill exercise and reach that threshold, that heart rate threshold that allows them to exercise just below the anaerobic threshold, long winded answer. But I hope that gives you some kind of guidance. Um Great talk. Thank you. As you mentioned briefly that when you hear a home before about it, one of the hottest trends in social science physiology these days. Yeah, hopefully accomplishing more and less time where we stand in terms of the evidence based group. So there are proponents of high intensity interval training and there are those who don't support it. I think you have to be very careful in terms of who you're prescribing it for because, you know, in terms of the physicality, the balance and functional ability, whether whatever machine you're on, you have to make sure you've selected the right patient. And in terms of, you know, stability, medical stability. So my population arrhythmias and heart failure and ischemia, we have to be careful that we're not putting them into a zone where they're going to have abnormalities. But that's the value of doing the stress test before you prescribe an exercise program for someone. Because hopefully they've reached the peak of exercise on that stress test. So you understand where they are, when they reach their high intensity in the cardiac field, uh there's strong evidence that it's beneficial and not more risky, but it doesn't prove or doesn't show from the literature that I've reviewed that it's any better than steady state. Then it comes down to the individual patient because many times patients will prefer to do a shorter course of therapy, a more intense exercise session. They're not getting greater benefits than those people who are doing the full session of steady state, but they're getting as good improvements and with no greater risk in the right selected population, I have not seen literature on high intensity interval training in stroke. Although I imagine based on what I saw a week or so ago that out of Chicago, we're gonna have some data in the not too distant future, nor in cancer or brain injury. But that's where the research needs to come in, but it's safe, it's effective but not more effective than steady state exercise. It's a trend that many folks are enjoying. Certainly younger and maybe more balanced and mobile happened. Drink. I know really important for. Yeah. So I did, I did, I think, put a little disclaimer. I said a little disclaimer that I'm not going to be talking about resistance training or strength training. Although, and it's absolutely right. One of my colleagues in the cancer rehab world, every time I say, oh, we got to focus on aerobic training, he says, and strength training and strength training. Yes, absolutely right. So this whole idea of frailty and sarcopenia is absolutely related to sort of a catalog state that we see in cancer, but many other conditions, heart failure as well, loss of muscle mass loss of muscle function in the pulmonary world as well in patients who have been on steroids where their muscles aren't working normally and steroid myopathy. So, absolutely. Yes. Again, it would be another lecture. I'll come back, I'll do another lecture on, on strength training. But you're absolutely right. You know, it's, I'm, I'm a little biased and I, I didn't give resistance training enough of a comment, but it should be on an equal setting. A great talk. And I really appreciate the evidence that you presented and it motivates all of us personally to think about increasing our activity. I think you need to come up with another lecture on how to deal with the financial planning that my money is running out in 92. And you're telling me I'm gonna live to 100. So I exercise more to save more money. So it's a really challenging thing to be done. Iii I wouldn't be so bold as to give you financial or life planning, but don't stop working because you're gonna live a long time. Good point though. I just wanted to know like, what strategies have you found that you use in order to help your patients kind of stay consistent with this lifestyle after done with? Yeah. So I follow with my patients life long until they are sick of me and bored of me and don't come back. I keep inviting them back with us every three months, every six months, every year, they come back to see me. I play the role of their primary care doctor and I don't, it's not about the exam, it's about the interaction and, and, and I treat my patients. II I tell them, I say, you know, you're a human being, I'm a human being. I really care for you. Like you're my brother, you're my sister, you're my loved one. I really care about you. I'm really invested in your health and your well being. So it really is about being human with them and when I'm human with them, they're more likely. And I found that they trust me and they follow along with what I do. I think it's very important to set an example I live and I can share my examples with them. I have bad knees. I talk to them about my knees and what I have to do to take care of my knees while I continue to exercise. So I try to be as human as possible with them. Not the doctor, them, not the patient, uh, build a report and they keep coming back and they, you know, they have their wobbles, they'll message me, we have epic as well and they'll message me, you know, I didn't exercise for two weeks. I'm not sure what I should do now to restart. So I wanna live with them. So it's, it's a commitment. But, you know, that's the, you couldn't pay me enough money to satisfy me. I mean, I don't think, I think that goes the same for all of us. It's not a matter of money. It's what you feel inside and what you can give to each individual patient and the community that you live in. I think that's really what it comes down to for me. Thank you very much. Thank you. Yeah. So, so, so again, listen, I think diet is so important. I married a nutritionist. So, yes, you are you a nutritionist? No. Yeah. Ok. But, but diet is essential, of course. Yeah, another lecture. Created by
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